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NPI Code Detail

MEDICARE: DR. MARK J. GRUNBERG D.D.S.

MEDICARE: DR. MARK J. GRUNBERG D.D.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice DentistryIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1962407239
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARK J. GRUNBERG D.D.S.
Provider Business Mailing Address
First Line : 3758 W CHICAGO AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60651-3823
Country : US
Telephone Number : 773-276-6600
Fax Number :
Provider Business Practice Location Address
First Line : 3758 W CHICAGO AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60651-3823
Country : US
Telephone Number : 773-276-6600
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2005
Last Update Date : 07/09/2007

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